Nokea
A 17-year-old client had one generalized convulsion several hours prior to admission to the medical unit for a neurological workup. Physician's orders include Dilantin (phenytoin) 100 mg orally (PO) tid and phenobarbital 100 mg PO daily. He tells the nurse, 'I can't believe I really had a seizure. My mom says she was in the room when it happened, but I don't even remember it.' What is the best interpretation of his comments?
- A. They indicate an initial denial mechanism, but he will begin to remember the seizure later.
- B. Anoxia suffered during the seizure has damaged part of his cerebral cortex.
- C. Inability to remember the seizure is a normal response of a person who has had a seizure.
- D. They are an indication that he would rather not talk about his seizure at this time.
Correct Answer: C
Rationale: Amnesia for the seizure event is a normal response due to altered consciousness during a generalized seizure.
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The client is scheduled for right-eye cataract removal surgery in five (5) days. Which preoperative instruction should be discussed with the client?
- A. Administer dilating drops to both eyes for 72 hours prior to surgery.
- B. Prior to surgery do not lift or push any objects heavier than 15 pounds.
- C. Make arrangements for being in the hospital for at least three (3) days.
- D. Avoid taking any type of medication which may cause bleeding, such as aspirin.
Correct Answer: D
Rationale: Avoiding bleeding-risk medications like aspirin prevents intraoperative hemorrhage. Dilating drops are not used for 72 hours, lifting restrictions are postoperative, and cataract surgery is typically outpatient.
The client has undergone a bilateral stapedectomy. Which action by the client warrants immediate intervention by the nurse?
- A. The client is ambulating without assistance.
- B. The client is sneezing with the mouth open.
- C. There is some slight serosanguineous drainage.
- D. The client reports hearing popping in the affected ear.
Correct Answer: A
Rationale: Ambulating without assistance post-stapedectomy risks vertigo and falls, requiring intervention. Open-mouth sneezing, slight drainage, and popping are expected.
The nurse completes an assessment of the older adult client. Which disorder should the nurse associate with the finding illustrated?
- A. Glaucoma
- B. Arcus senilis
- C. Cataract
- D. Mydriasis
Correct Answer: C
Rationale: The illustration shows opacity of the lens of the eye. The nurse should associate this finding with a cataract. Glaucoma causes increased pressure within the eye and is not visible. Arcus senilis is a bluish-white ring within the outer edge of the cornea, which is not present in this illustration. Mydriasis is constriction of the pupil, which is not present in the illustration.
The 72-year-old client tells the nurse food does not taste good anymore and he has lost a little weight. Which information should the nurse discuss with the client?
- A. Suggest using extra seasoning when cooking.
- B. Instruct the client to keep a seven (7)-day food diary.
- C. Refer the client to a dietitian immediately.
- D. Recommend eating three (3) meals a day.
Correct Answer: B
Rationale: A food diary identifies intake patterns and weight loss causes, guiding intervention. Extra seasoning is premature, dietitian referral is secondary, and three meals are standard advice.
The client is scheduled for laser-assisted in situ keratomileusis (LASIK) surgery for severe myopia. Which instruction should the nurse discuss prior to the client's discharge from day surgery?
- A. Wear bilateral eye patches for three (3) days.
- B. Wear corrective lenses until the follow-up visit.
- C. Do not read any material for at least one (1) week.
- D. Teach the client how to instill corticosteroid ophthalmic drops.
Correct Answer: D
Rationale: Corticosteroid drops reduce inflammation post-LASIK, requiring teaching. Eye patches are not used, corrective lenses are unnecessary, and reading restrictions are shorter.